Provider Demographics
NPI:1700984614
Name:PENINSULA COMMUNITY HEALTH SERVICES OF ALASKA, INC.
Entity Type:Organization
Organization Name:PENINSULA COMMUNITY HEALTH SERVICES OF ALASKA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:WRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-260-7314
Mailing Address - Street 1:PO BOX 2949
Mailing Address - Street 2:
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669-2949
Mailing Address - Country:US
Mailing Address - Phone:907-260-7300
Mailing Address - Fax:907-260-7301
Practice Address - Street 1:230 E MARYDALE AVE
Practice Address - Street 2:
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669-7648
Practice Address - Country:US
Practice Address - Phone:907-260-7300
Practice Address - Fax:907-260-7301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK706967103TC0700X, 1041C0700X, 122300000X, 207Q00000X, 363AM0700X, 363LC1500X
AK2093174400000X
AK703967261QF0400X
261QF0400X
AK737363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
No363LC1500XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCommunity HealthGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKHC5786OtherMEDICAID PROJECT CHOICE
AKK162666OtherMEDICARE PTAN
AKRH177FQMedicaid
AKDDG26FQMedicaid
AKK162666OtherMEDICARE PTAN
AKK162666OtherMEDICARE PTAN
AKMH0156Medicaid